Bloused stent-graft and fenestration method

ABSTRACT

A method includes deploying a bloused stent-graft into a main vessel such that a bloused section of the bloused stent-graft covers a branch vessel emanating from the main vessel. The bloused section includes loose graft cloth. A pressure differential between the main vessel and the branch vessel causes the bloused section to be forced into an ostium of the branch vessel creating a pocket aligned with the branch vessel. A distal tip of a puncture device is located in the pocket and thus aligned with the branch vessel. An outward force is applied to the puncture device to cause the distal tip of the puncture device to fenestrate the bloused section thus creating a collateral opening in the bloused section precisely aligned with the branch vessel.

BACKGROUND OF THE INVENTION

1. Field of the Invention

The present invention relates to an intra-vascular device and method.More particularly, the present invention relates to a device fortreatment of intra-vascular diseases.

2. Description of Related Art

A conventional main (vessel) stent-graft typically includes a radiallyexpandable reinforcement structure, formed from a plurality of annularstent rings, and a cylindrically shaped layer of graft material,sometimes called graft cloth, defining a lumen to which the stent ringsare coupled. Main stent-grafts are well known for use in tubular shapedhuman vessels.

To illustrate, endovascular aneurysmal exclusion is a method of using amain stent-graft to exclude pressurized fluid flow from the interior ofan aneurysm, thereby reducing the risk of rupture of the aneurysm andthe associated invasive surgical intervention.

Main stent-grafts with custom side openings are sometimes fabricated toaccommodate the particular vessel geometry of each individual patient.Specifically, as the location of branch vessels emanating from a mainvessel, e.g., having the aneurysm, varies from patient to patient, mainstent-grafts are fabricated with side openings customized to match theposition of the branch vessels of the particular patient. However,custom fabrication of main stent-grafts is relatively expensive and timeconsuming.

To avoid custom fabrication of main stent-grafts, side openings in themain stent-graft may be formed in situ. Illustratively, the mainstent-graft is placed in the main vessel, e.g., the aorta, to exclude ananeurysm. Fenestrations may be made in situ to correspond to adjacentbranches.

The graft material of the main stent-graft is pierced with a needle atthe ostium of a branch vessel, e.g., the renal artery, emanating fromthe main vessel. Alignment of the needle with the center of the ostiumof the branch vessel is accomplished using radiopaque markers on theneedle. However, due to difficulties in accurately placement of theneedle, the graft material of the main stent graft is often piercedoffset from the center of the ostium of the branch vessel, which isundesirable.

SUMMARY OF THE INVENTION

In accordance with one example, a method includes deploying a blousedstent-graft into a main vessel such that a bloused section of thebloused stent-graft covers a branch vessel emanating from the mainvessel. The bloused stent-graft includes a proximal section, a distalsection, and the bloused section attached to and between the proximalsection and the distal section. The bloused section includes loose graftcloth.

A pressure differential between the main vessel and the branch vesselcauses the bloused section to be forced into an ostium of the branchvessel creating a pocket aligned with the branch vessel.

A distal tip of a puncture device is located in the pocket and thusaligned with the branch vessel. An outward force is applied to thepuncture device to cause the distal tip of the puncture device tofenestrate the bloused section thus creating a collateral opening in thebloused section precisely aligned with the branch vessel.

As set forth above, by forming the bloused section with loose graftcloth, the pocket is self-aligned with the branch vessel as the loosegraft cloth is forced into the branch vessel. The pocket, in turn,facilitates self-alignment of the puncture device with the branchvessel. Accordingly, fenestration of the bloused section with thepuncture device creates the collateral opening precisely aligned withthe branch vessel.

Embodiments are best understood by reference to the following detaileddescription when read in conjunction with the accompanying drawings.

BRIEF DESCRIPTION OF THE DRAWINGS

FIG. 1 is a perspective view of a bloused stent-graft in accordance withone embodiment;

FIG. 2 is a cross-sectional view of the bloused stent-graft of FIG. 1;

FIG. 3 is a cross-sectional view of a vessel assembly including thebloused stent-graft of FIGS. 1 and 2 in accordance with one embodiment;

FIG. 4 is an enlarged cross-sectional view of a region IV of the vesselassembly of FIG. 3;

FIG. 5 is an enlarged cross-sectional view of the vessel assembly ofFIG. 4 during fenestration of the bloused stent-graft;

FIG. 5 A is an enlarged schematic cross-sectional view of the vesselassembly of FIG. 4 showing an alternate configuration to that shown inFIG. 5; and

FIG. 6 is an enlarged schematic cross-sectional view of the vesselassembly of FIG. 5 after fenestration of the bloused stent-graft.

Common reference numerals are used throughout the drawings and detaileddescription to indicate like elements.

DETAILED DESCRIPTION

Referring to FIG. 3, a method includes deploying a bloused stent-graft100 into a main vessel 302 such that a bloused section 110 of blousedstent-graft 100 covers a branch vessel 306 emanating from main vessel302. Bloused section 110 includes loose graft cloth.

Referring now to FIGS. 3 and 4 together, a pressure differential betweenmain vessel 302 and branch vessel 306 causes bloused section 110 to beforced into an ostium 310 of branch vessel 306 creating a pocket 316precisely aligned with branch vessel 306.

Referring now to FIG. 5, a distal tip 504 of a steerable puncture device502 is located in pocket 316 and thus precisely aligned with branchvessel 306. An outward force is applied to steerable puncture device 502to cause distal tip 504 of steerable puncture device 502 to fenestratebloused section 110 thus creating a collateral opening 602 (FIG. 6) inbloused section 110 precisely aligned with branch vessel 306.

Referring now to FIG. 5A, a distal tip 504 of a steerable puncturedevice 502 is contained within a guide catheter 702 located in pocket316 and thus the puncture device is positioned to be precisely alignedwith branch vessel 306. An outward force is applied to steerablepuncture device 502 to move it forward within the guide catheter 702 tocause distal tip 504 of steerable puncture device 502 to fenestratebloused section 110 thus creating a collateral opening 602 (FIG. 6) inbloused section 110 precisely aligned with branch vessel 306.

More particularly, FIG. 1 is a perspective view of a bloused stent-graft100, e.g., an abdominal aortic stent-graft, in accordance with oneembodiment. Referring now to FIG. 1, bloused stent-graft 100 includesstent rings 102, 104, 106. Illustratively, stent rings 102, 104, 106 areself-expanding stent rings, e.g., formed of Nitinol. The inclusion ofbare stent ring 102 is optional.

FIG. 2 is a cross-sectional view of bloused stent-graft 100 of FIG. 1.In FIG. 2, stent rings 102, 104, 106 are not illustrated for clarity ofpresentation.

Referring now to FIGS. 1 and 2 together, bloused stent-graft 100includes a proximal section 108, a bloused section 110, and a distalsection 112, sometimes called a proximal segment, a bloused segment anda distal segment, respectively. Bloused section 110 is attached to andbetween proximal section 108 and distal section 112. A series of “V”shaped pleats are shown at the top and bottom of the bloused section, tocause the larger diameter cylindrical blouse section material to benarrowed to match the proximal 108 and distal section 112 smallerdiameters.

As used herein, the proximal end of a prosthesis such as a stent-graftis the end closest to the heart via the path of blood flow whereas thedistal end is the end furthest away from the heart during deployment. Incontrast and of note, the distal end of the catheter is usuallyidentified to the end that is farthest from the operator (handle) whilethe proximal end of the catheter is the end nearest the operator(handle).

For purposes of clarity of discussion, as used herein, the distal end ofthe catheter (steerable puncture device) is the end that is farthestfrom the operator (the end furthest from the handle) while the distalend of the prosthesis is the end nearest the operator (the end nearestthe handle), i.e., the distal end of the catheter and the proximal endof the stent-graft are the ends furthest from the handle while theproximal end of the catheter and the distal end of the stent-graft arethe ends nearest the handle. However, those of skill in the art willunderstand that depending upon the access location, the stent-graft anddelivery system description may be consistent or opposite in actualusage.

Proximal section 108 includes a proximal end 108P and a distal end 108D.Bloused section 110 includes a proximal end 110P and a distal end 110D.Distal end 108D of proximal section 108 is attached to proximal end 110Pof bloused section 110 by an attachment means 114. Illustratively,attachment means 114 is stitching, adhesive, thermal bonding, or otherattachment between proximal section 108 and bloused section 110.

Distal section 112 includes a proximal end 112P and a distal end 112D.Proximal end 112P of distal section 112 is attached to distal end 110Dof bloused section 110 by an attachment means 116. Illustratively,attachment means 116 is stitching, adhesive, thermal bonding, or otherattachment between bloused section 110 and distal section 112.

Bloused stent-graft 100 includes a proximal main opening 118 at aproximal end 100P on bloused stent-graft 100 and a distal main opening120 at a distal end 100D of bloused stent-graft 100. Further, blousedstent-graft 100 includes a longitudinal axis L. A main lumen 122 isdefined by bloused stent-graft 100 and extends generally parallel tolongitudinal axis L and between proximal main opening 118 and distalmain opening 120 of bloused stent-graft 100.

Proximal section 108 and distal section 112 are cylindrical havingsubstantially uniform diameters D1, D2, respectively. In contrast,bloused section 110 has a non-uniform diameter having minimum diametersD1, D2 at proximal end 110P and distal end 110D and ballooning outward(increasing in diameter) therefrom.

In one embodiment, proximal section 108 is a first cylindrical piece ofgraft material, e.g., graft cloth, having a diameter D1. Distal section112 is a second cylindrical piece of graft material, e.g., graft cloth,having a diameter D2. In the example illustrated in FIGS. 1 and 2,diameter D1 is equal to diameter D2, although in other examples diameterD1 is greater than diameter D2 or vice versa.

Bloused section 110 is formed from a third cylindrical piece of graftmaterial, e.g., graft cloth, that has a diameter for example 50% largerthan diameters D1, D2 of proximal section 108 and distal section 112,respectively. The ends of this cylindrical piece of graft material areattached, e.g., sewn, to proximal section 108 and distal section 112creating bloused section 110. The bloused section must be large enoughbe seen under fluoroscopy which is expected when the peak diameter ofthe bloused section is from 10 to 60% larger than either adjacentsection diameter D1 or D2. Accordingly, bloused section 110 balloons,sometimes called bulges, protrudes or extends, outward from proximalsection 108 and distal section 112. The maximum diameter D3 of blousedsection 110 is greater than diameter D1 or diameter D2. Bloused section110 includes pleated loose graft cloth at each end where attachment toadjacent diameters D1, D2, sometimes called excess graft cloth, anoverlarge bloused segment of graft cloth or slack graft cloth. Inaddition to pleating, another sewing method that could be used to attachthe ends of the large diameter bloused section to the smaller diametercylindrical section is “gathering” wherein what is meant here is that atiny bit of extra cloth is gathered under each stitch to capture morematerial, i.e., a micropleat. Additionally the bloused portion could bespecially woven to have cylindrically concave shape (so a cylindricalsection of stent graft extends outwardly outside the proximal and distaldiameters in an approximately spherical, ellipsoid, or similarcontinuous bulging surface shape) to avoid the need to have narrowed endportions such as provided by bunching, pleating, or gathering. Thebloused section could also be constructed by using a cylindrical sectionof graft material of the larger bloused section maximum diameter andcutting pie shaped sections from both the proximal and distal end of thematerial at for example six evenly spaced circumferential locationsaround each end and sewing the sides of the remaining portions of thegraft material (petal shaped sections) so that then the diameters ofboth the proximal and distal ends of the bloused section substantiallymatch and can be sewn (or otherwise attached) to the proximal and distalsubstantially constant diameter end sections. In contrast, proximalsection 108 and distal section 112 are circumferentially taut, i.e.,have little to no give or slack.

Referring again to FIG. 1, in accordance with one example, blousedsection 110 includes radiopaque ink 124 that allows visualization ofbloused section 110. In one example, radiopaque ink 124 is applied,e.g., printed, as a stipple pattern to the graft material of blousedsection 110. In this manner, flexibility of bloused section 110 ismaintained while at the same time visualization of bloused section 110is facilitated. However, in another embodiment, a bloused sectionsimilar to bloused section 110 is formed with an absence of radiopaqueink.

Stent ring 102, e.g., a first stent ring, is attached, e.g., sewn, toproximal section 108 at proximal end 108P thereof. Stent ring 102,sometimes called a suprarenal stent ring, extends proximally fromproximal section 108. This stent ring is optional.

Stent ring 104, e.g., a second stent ring, is attached, e.g., sewn, toproximal section 108. Similarly, stent ring 106, e.g., a third stentring, is attached, e.g., sewn, to distal section 112.

Stent rings 102, 104, 106, are self-expanding facilitating expansion,fixation, and sealing of bloused stent-graft 100 into the main vessel asdiscussed further below. In another example, a bloused stent-graftsimilar to bloused stent-graft 100 is formed with stent rings that areballoon expanded facilitating fixation and sealing of the blousedstent-graft into the main vessel. Bloused section 110 has an absence ofstent rings.

Although three stent rings 102, 104, 106 are illustrated, in otherexamples, a bloused stent-graft similar to bloused stent-graft 100 isformed with more or less than three stent rings or other self-expandingmembers.

FIG. 3 is a cross-sectional view of a vessel assembly 300 includingbloused stent-graft 100 of FIGS. 1 and 2 in accordance with oneembodiment. Referring now to FIG. 3, a main vessel 302, e.g., the aorta,includes an aneurysm 304. Bloused stent-graft 100, sometimes called aprosthesis, is deployed into main vessel 302 to exclude aneurysm 304using any one of a number of techniques well known to those of skill inthe art.

Emanating from main vessel 302 is a first branch vessel 306 and a secondbranch vessel 308, sometimes called visceral branches of the abdominalaorta. The location of branch vessels 306, 308 vary from patient topatient. Examples of branch vessels include the renal arteries (RA) andthe superior mesenteric artery (SMA).

Bloused stent-graft 100 is deployed such that bloused section 110 isaligned with branch vessels 306, 308. Stated another way, blousedstent-graft 100 is deployed such that blouse section 110 covers ostia(plural of ostium) 310, 312 of branch vessels 306, 308, respectively.

Proximal section 108 is located proximally to ostia 310, 312 of branchvessels 306, 308. Accordingly, bloused stent-graft 100 is deployed withfixation and sealing superior to branch vessels 306, 308. Distal section112 is located distally to ostia 310, 312 of branch vessels 306, 308.

Stent rings 102, 104, 106 are radially expandable reinforcementstructures that self-expand into a vessel wall 314 of main vessel 302thus anchoring bloused stent-graft 100 in place. Bloused stent-graft 100is delivered to main vessel 302 and deployed therein using any one of anumber of techniques well known to those of skill in the art.

Once anchored within main vessel 302, blood flows through main lumen 122and more generally through bloused stent-graft 100 thus excludinganeurysm 304. Further, blood pressure within bloused stent-graft 100creates pockets 316, 318 within bloused section 110. More particularly,the pressure inside of bloused stent-graft 100 is greater than thepressure within branch vessels 306, 308. Due to this pressuredifferential, bloused section 110, which is loose, is forced into ostia310, 312 of branch vessels 306, 308 creating pockets 316, 318,respectively. Accordingly, pockets 316, 318, sometimes called first andsecond pockets, are precisely aligned with ostia 310, 312, sometimescalled first and second ostia, of branch vessels 306, 308, sometimescalled first and second branch vessels, respectively.

To illustrate, FIG. 4 is an enlarged cross-sectional view of a region IVof vessel assembly 300 of FIG. 3. As illustrated in FIG. 4, blousedsection 110 follows the contour of vessel wall 314 of main vessel 302.Further, bloused section 110 follows the contour of ostium 310, which isillustrated as being enlarged due to disease.

Pocket 316 is a region defined by the portion of bloused section 110extending radially outward into branch vessel 306. Pocket 316 is theregion between an imaginary cylindrical surface defined by vessel wall314 as indicated by the dashed line 402 in FIG. 4 to the portion ofbloused section 110 extending radially outward into branch vessel 306.Pocket 316 includes an apex 404, i.e., the most radial outward portionof bloused section 110. Bloused section 110 tapers radially outward in arounded conical shape to apex 404 from vessel wall 314. Apex 404, andmore generally, pocket 316, is precisely aligned with branch vessel 306.

Returning to FIG. 3, the location of branch vessels 306, 308 arelongitudinally offset from one another. However, as bloused section 110is aligned with both of branch vessels 306, 308, pocket 318 is preciselyaligned with branch vessel 308 in a manner similar to that discussedabove regarding alignment of pocket 316 with branch vessel 306 and so isnot repeated here.

FIG. 5 is an enlarged cross-sectional view of vessel assembly 300 ofFIG. 4 during fenestration of bloused stent-graft 100. Referring now toFIG. 5, to form a side opening, sometimes called a collateral opening,in bloused stent-graft 100, and more particularly, bloused section 110,corresponding to (at) branch vessel 306, a steerable puncture device 502is advanced to the location of branch vessel 306. Steerable puncturedevices similar to steerable puncture device 502 are well known to thoseof skill in the art.

Steerable puncture device 502 is oriented radially, e.g., at a 90 degreeangle, relative to longitudinal axis L and thus points at blousedsection 110 of bloused stent-graft 100. More particularly, a distal tip504 of steerable puncture device 502 is located within pocket 316 andrests against (contacts) apex 404. Accordingly, steerable puncturedevice 502 is precisely aligned with branch vessel 306.

In one example, steerable puncture device 502 includes a radiopaquemarker 506 that allows visualization of steerable puncture device 502.As set forth above, in one example, bloused section 110 includesradiopaque ink 124 that allows visualization of bloused section 110.Accordingly, both steerable puncture device 502 and bloused section 110are visualized to ensure precise alignment of steerable puncture device502 within pocket 316.

Further, in one example, in the event of initial misalignment ofsteerable puncture device 502 with apex 404 as illustrated by thephantom lines 508, outward radial force on steerable puncture device 502causes steerable puncture device 502 to slide down the taper of pocket316 and to apex 404. Once located at apex 404, further outward force onsteerable puncture device 502 causes distal tip 504, e.g., a sharp tip,to fenestrate (penetrate) bloused section 110 precisely in alignmentwith branch vessel 306.

FIG. 5A is an enlarged cross-sectional view of vessel assembly 300 ofFIG. 4 during an alternate method of fenestration of bloused stent-graft100. Referring now to FIG. 5A, to form a side opening, sometimes calleda collateral opening, in bloused stent-graft 100, and more particularly,bloused section 110, corresponding to (at) branch vessel 306, asteerable guide catheter 702 (such as those manufactured by Enpath andCardima) having a puncture device 502 contained therein is advanced tothe location of branch vessel 306. The end of the steerable guidecatheter is blunt to minimize the chances of the end of the devicecatching in the graft cloth. A blunt or rounded end permits smoothsliding of the end of steerable catheter in contact with the graft(pocket) surface. The puncture device can be advanced simultaneouslywith the steerable guide catheter, or can be inserted within thesteerable guide catheter after the steerable guide catheter has beenpositioned within the bloused pocket.

The end of steerable guide catheter 702 with the puncture device 502contained therein is oriented radially, e.g., at a 90 degree angle,relative to longitudinal axis L and thus points at bloused section 110of bloused stent-graft 100. More particularly, a distal tip of the guidecatheter 702 is located within pocket 316 and rests against (contacts)apex 404. Accordingly, the puncture device 502 contained in thesteerable guide catheter 702 is precisely aligned with branch vessel306.

As is well known in the art, steerable guide catheters are constructedof materials which provide visualization of its position underfluoroscopy. As set forth above, in one example, bloused section 110includes radiopaque ink 124 that allows visualization of bloused section110. Accordingly, both steerable guide catheter 702 and bloused section110 are visualized to ensure precise alignment of the steerable guidecatheter 702 and puncture device 502 within pocket 316.

Further, in one example, in the event of initial misalignment of thesteerable guide catheter 702 with the puncture device 502 containedtherein with apex 404 as illustrated by the phantom lines 708, outwardradial force on the guide catheter 702 causes the blunt end of the guidecatheter 702 to slide down the taper of pocket 316 and to apex 404. Oncethe steerable guide catheter is located at apex 404, the puncture deviceis advanced within the steerable guide catheter 702 to contact thebloused section of graft material, further outward force on the puncturedevice 502 allows its distal tip 504, e.g., a sharp tip, to fenestrate(penetrate) bloused section 110 precisely in alignment with branchvessel 306.

FIG. 6 is an enlarged schematic cross-sectional view of vessel assembly300 of FIGS. 5 and 5A after fenestration of bloused stent-graft 100.Referring now to FIGS. 5, 5A, and 6 together, after fenestration ofbloused section 110 with steerable puncture device 502 and removal ofsteerable puncture device 502, a collateral opening 602 is formed inbloused stent-graft 100. More particularly, collateral opening 602 isformed in bloused section 110. Collateral opening 602 facilitates bloodflow from main lumen 122 of bloused stent-graft 100 through collateralopening 602 and into branch vessel 306, thus perfusing branch vessel306. Further, bloused section 110 follows the contour of ostium 310effectively forming a branch graft 604 extending into branch vessel 306.

By forming bloused section 110 with loose graft cloth, pocket 316 isself-aligned with branch vessel 306 as the loose graft cloth is forcedinto branch vessel 306. Pocket 316, in turn, facilitates self-alignmentof steerable puncture device 502 with branch vessel 306. Accordingly,fenestration of bloused section 110 with steerable puncture device 502creates collateral opening 602 precisely aligned with branch vessel 306.

Returning now to FIGS. 3, 4, 5, 5A, and 6 together, steerable puncturedevice 502 is used to form a collateral opening in bloused stent-graft100 in alignment with branch vessel 308 in a similar manner to formationof collateral opening 602 as discussed above and so is not repeatedhere. In accordance with the above example, a method of fenestration insitu of bloused stent-graft 100 is provided to address the problem ofperfusing visceral branches of the abdominal aorta with an abdominalaortic aneurysm 304 in which bloused stent-graft 100 is deployed withfixation and sealing superior to the renal arteries (RA) and superiormesenteric artery (SMA).

This disclosure provides exemplary embodiments. The scope is not limitedby these exemplary embodiments. Numerous variations, whether explicitlyprovided for by the specification or implied by the specification ornot, such as variations in structure, dimension, type of material andmanufacturing process may be implemented by one of skill in the art inview of this disclosure.

1-15. (canceled)
 16. A method comprising: deploying a blousedstein-graft into a main vessel such that a bloused section of saidbloused stent-graft covers a first branch vessel emanating from saidmain vessel, said bloused stent-graft comprising: a proximal sectioncomprising a first cylindrical piece of graft material having a firstdiameter; a first stent ring attached to said proximal section; a distalsection comprising a second cylindrical piece of graft material having asecond diameter; a second stent ring attached to said distal section;and said bloused section attached to and between said proximal sectionand said distal section, said bloused section comprising loose graftcloth, wherein said bloused section comprises a third cylindrical pieceof graft material having a third diameter greater than said firstdiameter and said second diameter, said bloused section comprisingv-shaped pleats to cause said third diameter to be narrowed to saidfirst diameter and said second diameter at ends of said thirdcylindrical piece of graft material, wherein said ends of said thirdcylindrical piece of graft material are attached to said proximalsection and said distal section to form said bloused section, wherein apressure differential between said main vessel and said first branchvessel causes said bloused section to be forced into an ostium of saidfirst branch vessel creating a pocket aligned with said first branchvessel; and locating a distal tip of a puncture device in said pocket.17. The method of claim 16 wherein said pocket is defined by a portionof said bloused section extending into said first branch vessel.
 18. Themethod of claim 16 wherein said pocket comprises an apex, said blousedsection tapering radially outward from a vessel wall of said main vesselto said apex.
 19. The method of claim 16 wherein said puncture device isoriented radially relative to a longitudinal axis of said blousedstent-graft within said pocket.
 20. The method of claim 16 wherein saiddistal tip of said puncture device contacts an apex of said pocket. 21.The method of claim 16 wherein said puncture device comprises aradiopaque marker and wherein said bloused section comprises radiopaqueink facilitating visualization of alignment of said puncture devicewithin said pocket.
 22. The method of claim 16 wherein said puncturedevice comprises a guide catheter being fluoroscopically visible andwherein said bloused section comprises radiopaque ink facilitatingvisualization of alignment of said guide catheter within said pocket.23. The method of claim 22, wherein said guide catheter is a steerableguide catheter.
 24. The method of claim 16 wherein said locating adistal tip of a puncture device in said pocket comprises applying anoutward radial force on said puncture device to cause said puncturedevice to slide down a taper of said pocket to an apex of said pocket.25. The method of claim 22 wherein said locating a distal tip of apuncture device in said pocket comprises applying an outward radialforce on said guide catheter to cause said guide catheter to slide downa taper of said pocket to an apex of said pocket.
 26. The method ofclaim 16 further comprising applying outward force on said puncturedevice to cause said distal tip of said puncture device to fenestratesaid bloused section in alignment with said first branch vessel.
 27. Themethod of claim 22, wherein a puncture device catheter is containedwithin said guide catheter and further comprising applying outward forceon said puncture device catheter to cause said distal tip of saidpuncture device to fenestrate said bloused section in alignment withsaid first branch vessel.
 28. The method of claim 26 wherein saidfenestration of said bloused section comprises creating a collateralopening in said bloused section, said collateral opening being alignedwith said first branch vessel.
 29. The method of claim 28 wherein saidfirst branch vessel is perfused through said collateral opening.
 30. Themethod of claim 28 wherein said bloused section follows a contour of anostium of said first branch vessel forming a branch graft extending intosaid first branch vessel.
 31. (canceled)